Ovarian cancer

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About the ovaries

Ovaries form part of the female reproductive system. Between puberty and the menopause the ovaries release an egg regularly, usually about every 28 days. Eggs travel down the fallopian tubes to the uterus. If a pregnancy doesn’t occur, they are shed with the lining of the womb each month as the menstrual period.

The ovaries also produce oestrogen and progesterone, the female sex hormones which control the menstrual cycle (periods).

During the months before the menopause the ovaries gradually stop working. Eggs are no longer produced and oestrogen levels fall. The symptoms which some women have at this time are due to the fall in oestrogen levels.

What causes ovarian cancer?

The cause of ovarian cancer is not yet known, but there are some factors that may increase your risk and some factors which may reduce your risks of ovarian cancer. These factors include:

your family history of cancer

whether you take the contraceptive pill

whether you have had children

breast-feeding

fertility treatment

talcum powder.

Many of these risk or protection factors seem to be associated with how the ovaries function. Ovarian cancer is not infectious, so you cannot catch it from anyone else and there is no evidence to suggest that sexual activity and ovarian cancer are linked. However, ovarian cancer is more common in developed countries (except Japan). It is believed that this maybe due to a high-fat diet in the western world and in particular, animal fat.

Family history of cancer

Women with two or more very close relatives who have had ovarian cancer are more at risk of getting the disease themselves. By very close relative, we mean mother, sister or daughter. Only about 5% to 10% of all ovarian cancers are thought to be hereditary.

BRCA1 and BRCA2 are two genes known to be associated with an increased risk of both breast and ovarian cancer. Families in which a fault on one of these genes is present are likely to have several individuals on the same side of the family affected with breast and/or ovarian cancer. In addition, families who have several closely related individuals affected with bowel cancer at a young age may carry a faulty gene which is associated with an increased risk of bowel cancer and ovarian cancer.

All of these genetic faults are rare but can be passed down through either parent.

If you are concerned about your family history of cancer, you can seek advice from your local genetics service (such as the one run by The Royal Marsden) through your GP or your hospital consultant.

Contraceptive pill

Taking the combined contraceptive pill (containing both oestrogen and progesterone) appears to reduce your risk of ovarian cancer. It is thought the longer you take the pill, the more your risk of ovarian cancer is decreased. By taking the combined contraceptive pill, you are not producing any eggs.

Children

Having children may decrease your risk of ovarian cancer, and not having children may increase your risk of ovarian cancer. This is because many of the risk or protection factors appear to be related to how the ovaries work. When your ovary produces an egg, the surface layer of the ovary bursts and releases an egg. The cells then divide to repair the damage. The more eggs your ovaries produce, the more the cells need to divide to repair the surface of the ovary. This increases the opportunity for any one cell to go wrong. During pregnancy, eggs stop being produced each month.

Breast-feeding

It is thought that breast-feeding your child reduces the risk of ovarian cancer. This is because when you breast feed, you do not normally produce an egg from the ovary each month. Therefore, this decreases ovarian activity.

Fertility treatment

There is no concrete evidence that taking fertility treatment does increase the risk of ovarian cancer. However, any drug which stimulates the ovary increases ovarian activity.

Talcum powder

There has been concern about the long-term use of talcum powder. Studies have suggested that the use of talcum powder in the genital area may lead to a slight increased risk of ovarian cancer. However, the current evidence is conflicting and inconclusive, and further large scale studies are needed in order to be able to reach a definite conclusion.

Screening

Screening programmes aim to pick up cancers at an early stage before they cause symptoms. There is not yet a reliable screening test to pick up ovarian cancer in the general population. Research trials are currently looking into the screening of women at high risk of cancer of the ovary and women in general.

The two main tests used in screening trials are:

blood test for CA 125

transvaginal ultrasound.

Screening is only available for women who may have an increased risk of developing ovarian cancer, such as women with a family history of the disease. If you are concerned that you may be at high risk, you can seek advice from your local genetics service (such as the one run by The Royal Marsden) through your GP or your hospital consultant.

Symptoms

Ovarian cancer often causes rather vague symptoms which makes it difficult to diagnose. These may include:

discomfort in the abdomen

swelling of the abdomen

feeling full or bloated

changes in bowel habits

frequency of passing urine.

You may have experienced some or all of these symptoms and this led you to consult your doctor in the first place. Cancer of the ovary may not be suspected until an operation is performed to find the cause of the symptoms. It may even be discovered by chance when having tests or treatment for another illness.

Ovarian cancer diagnosis

You will have some tests to confirm or rule out a diagnosis of ovarian cancer and to find out whether the cancer has spread to other parts of your body.

CA 125 level

CA 125 is a chemical which may be produced by ovarian cancer cells and released into the bloodstream. It is called a tumour marker and the level may be higher in women with ovarian cancer. However, the level isn’t always raised in early-stage ovarian cancer, and the level can be raised in women who have other non-cancerous conditions.

Your doctor will ask for a blood sample to be taken to measure your level of CA 125. The test will be repeated regularly as one part of the overall check on your progress during treatment.

Cytology

In some cases, women with ovarian cancer may notice that they have swelling of the abdomen or fluid collecting around their abdomen. This collection of fluid is called ascites and can cause bloating and discomfort.

Draining off the fluid will relieve this. The doctor can insert a cannula (small tube) into the abdomen to slowly drain the fluid over 24 to 48 hours. A local anaesthetic will be used to numb the area. A sample of this fluid can be removed and sent for cytology (the study of cells) where it will be examined to see if there are cancer cells present.

You may have other tests, which include an abdominal ultrasound, CT scan or MRI scan.

Staging

The information from these tests is used to assess the size of the cancer and how far it has spread. This is called ‘staging’. Your doctors need to know the extent of the cancer to help them decide on the most appropriate treatment for you.

Staging of ovarian cancer is based on a physical examination, the results of tests and what the doctors find at the time of surgery.

Ovarian cancer treatment

Cancer of the ovary is usually treated by a combination of surgery and chemotherapy. Radiotherapy is sometimes used to reduce symptoms. This is called palliative radiotherapy.

The team of doctors and nurses looking after you will plan your treatment based on your age, health and the type of tumour you have. This means that patients with the same type of cancer might have different treatment plans. You may have had an operation to confirm the diagnosis of ovarian cancer. An operation is also usually the first treatment for cancer of the ovary.

Surgery

The aim of surgery is to remove as much of the cancer as possible and to assess the extent of disease. How much tissue is removed during the operation will depend upon the results of the investigations that you will have before surgery. Your doctor will discuss the options with you, and no procedure will be undertaken without your consent.

The surgeon will remove the affected ovary and possibly the other ovary. Often, the womb will also need to be removed (this is called a hysterectomy) along with the fallopian tubes and part or all of the omentum (a layer of fatty tissue covering organs within the abdomen). This is called a total abdominal hysterectomy and bilateral salpingo-oophorectomy. The surgeon may also remove some lymph nodes to assess if there are any cancer cells within them.

Chemotherapy

Chemotherapy is usually given in addition to surgery, to ‘mop up’ any cancer cells left behind that are too small to detect. This will help reduce the possibility of the cancer returning. Occasionally, chemotherapy may be given to shrink the cancer before surgery.

After treatment for ovarian cancer

Having and being treated for ovarian cancer can have a huge effect on your life. You will also need to have regular checkups after treatment is finished.

Sex

Many women find their libido (sex drive) decreases during diagnosis and treatment of cancer. If you do lose interest in sex, don’t worry – this isn’t unusual. You may find it helps to talk to your partner about your feelings.

Cancer of the ovary isn’t contagious – you cannot pass on cancer to your partner through intercourse. If you have had a hysterectomy you may be advised to wait about six weeks before you have intercourse. This is to allow your body time to heal after the operation.

Fertility

Treatment for ovarian cancer in younger women can have an effect on their normal menstrual cycle (periods) and fertility (ability to have children).

Following a hysterectomy and removal of your ovaries you will no longer have periods and you can’t become pregnant. You will also have an early menopause. This could cause symptoms such as hot flushes, sweats and vaginal dryness. If such symptoms are troublesome, discuss the possibility of taking hormone replacement therapy (HRT) with your doctor or specialist nurse. Ask what other help is available if you have menopausal symptoms and don’t wish to consider taking HRT.

If you have had one ovary removed and haven’t had a hysterectomy, you may have periods and be fertile. During chemotherapy, even though your periods may be irregular or stop, you or your partner must use an effective method of contraception. Chemotherapy may damage the DNA development of a foetus, leading to the many risks associated with an abnormal pregnancy. Some chemotherapy drugs can also damage the ovary, leading to an increased risk of infertility and early menopause.

If you have any concerns about fertility, discuss the possibility of future pregnancies with your doctor before you start treatment.

Cancer returning

Ovarian cancer can come back. This happens when ovarian cancer cells leave the original (primary) site and spread through the lymphatic or blood system to other parts of the body.

When this happens, it means the cancer cannot be cured but it can often be controlled for a considerable time by having further chemotherapy or surgery. You may be offered the same or different chemotherapy drugs. Your doctor will discuss with you the treatment options available.

Learning that your cancer has returned can be an anxious time and you may feel overwhelmed with a variety of emotions. This is a normal reaction. While everyone finds their own way of coping at this time you may need extra help. Ask your doctor or specialist nurse for information about sources of further support and help. Although family and friends may be very helpful and supportive to you, you may find it helpful to talk things through with a counsellor.

Checkups

The doctor will ask you to attend hospital at regular intervals during and after your treatment. You will be given a clinic appointment; these will probably become less frequent as time passes. Each time the doctor will examine you and ask how you are feeling. Blood tests, X-rays and scans may be repeated to check your recovery and make sure the cancer hasn’t returned.